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OBJECTIVES: To examine the relationship between post-acute care (PAC) quality improvement and long-term care (LTC) quality changes. DESIGN: Observational study using national nursing home data from Nursing Home Compare linked to Brown University's LTCFocus data. SETTING AND PARTICIPANTS: Free-standing nursing homes serving PAC and LTC residents in the United States. METHODS: This study used pooled cross-sectional analysis with nursing home-level data from 2005 to 2010 (12,150 unique nursing homes). We used fixed effects models to examine the association between a 1-year change in PAC quality and a 1-year change in LTC quality, with a specific focus on related care domains. RESULTS: Strong and positive associations were found between related PAC and LTC care domains, particularly between the PAC and LTC influenza vaccination care domains (ß = 0.30, P < .001) and the PAC and LTC pneumococcal vaccination care domains (ß = 0.55, P < .001). Meanwhile, model results showed PAC quality changes essentially had no associations with unrelated LTC care domains. CONCLUSIONS AND IMPLICATIONS: This is the first study that examines the association of changes in quality between 2 overlapping but different care domains (ie, PAC and LTC) using multiple quality measures. Our findings indicate that nursing homes can manage concurrent quality improvement in PAC and LTC, particularly on care domains that are related. More research is needed to examine the mechanism that enables such concurrent quality improvement.

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BACKGROUND: Stroke is the leading cause for admission to the nearly 1,200 Inpatient Rehabilitation Facilities (IRFs) nationally in the US. For many patients, post-acute care is an important component of their rehabilitation. Several quality measures have been publicly reported for post-acute care providers, including hospital readmissions. However, to date none have focused on specific medical conditions, limiting the usability for patients and quality improvement. OBJECTIVE: To assess hospital readmission rates for Medicare patients receiving inpatient rehabilitation following stroke and to identify risk factors in order to evaluate the feasibility of a stroke-specific hospital readmission measure. METHODS: Observational study analyzing national Medicare inpatient claims and administrative data to assess hospital readmissions. Using logistic regression, we calculated unadjusted and risk-standardized readmission rates, which adjusted for patient characteristics, including type of stroke and admission function, to capture stroke severity. RESULTS: Our national study included 116,073 fee-for-service Medicare beneficiary discharged from IRFs in 2013-2014 following stroke from 1,162 IRFs nationally. The observed hospital readmission rate among IRF patients following stroke was 11.6% and varied by patients' admission motor function. Patients with greater functional dependence had higher readmission rates on average. Lower admission function, hemorrhagic and other stroke types (relative to ischemic) were significantly associated with higher odds of hospital readmission. CONCLUSION: Results suggest it is feasible to assess hospital readmission rates among a stroke-cohort treated in IRFs. Stroke-focused quality measures would be useful to patients in selecting a provider and for providers in evaluating their stroke rehabilitation program outcomes. Secondary results suggest that admission function (FIM) capture stroke severity, a limitation with other claims-based stroke measures.

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The first round of incentives and penalties under the Medicare Skilled Nursing Facility Value-Based Purchasing Program were distributed October 1, 2018. Our results show that facilities serving vulnerable groups were less likely to receive bonus payments and more likely to be penalized.

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Little research has explored the relationship between consumer satisfaction and quality in nursing homes (NHs) beyond the few states mandating satisfaction surveys. We examine this relationship through data from 1,765 NHs in the 50 states and District of Columbia using My InnerView resident or family satisfaction instruments in 2013 and 2014, merged with Certification and Survey Provider Enhanced Reporting, LTCfocus, and NH Compare (NHC) data. Family and resident satisfaction correlated modestly; both correlated weakly and negatively with any quality-of-care (QoC) and any quality-of-life deficiencies and positively with NHC five-star ratings; this latter positive association persisted after covariate adjustment; the negative relationship between QoC deficiencies and family satisfaction also remained. Overall, models explained relatively small proportions of satisfaction variance; correlates of satisfaction varied between residents and families. Findings suggest that satisfaction is a unique dimension of quality and that resident and family satisfaction represent different constructs.

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OBJECTIVE: To examine whether there are differences in inpatient rehabilitation facilities' (IRFs') all-cause 30-day postdischarge hospital readmission rates vary by organizational characteristics and geographic regions. DESIGN: Observational study. SETTING: IRFs. PARTICIPANTS: Medicare fee-for-service beneficiaries discharged from all IRFs nationally in 2013 and 2014 (N = 1166 IRFs). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: We applied specifications for an existing quality measure adopted by Centers for Medicare & Medicaid Services for public reporting that assesses all-cause unplanned hospital readmission measure for 30 days postdischarge from inpatient rehabilitation. We estimated facility-level observed and risk-standardized readmission rates and then examined variation by several organizational characteristics (facility type, profit status, teaching status, proportion of low-income patients, size) and geographic factors (rural/urban, census division, state). RESULTS: IRFs' mean risk-standardized hospital readmission rate was 13.00%±0.77%. After controlling for organizational characteristics and practice patterns, we found substantial variation in IRFs' readmission rates: for-profit IRFs had significantly higher readmission rates than did not-for-profit IRFs (P<.001). We also found geographic variation: IRFs in the South Atlantic and South Central census regions had the highest hospital readmission rates than did IRFs in New England that had the lowest rates. CONCLUSIONS: Our findings point to variation in quality of care as measured by risk-standardized hospital readmission rates after IRF discharge. Thus, monitoring of readmission outcomes is important to encourage quality improvement in discharge care planning, care transitions, and follow-up.

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OBJECTIVE: To re-examine the risk factors for shoulder dystocia given the increasing rates of obesity and diabetes in pregnant women. DESIGN: Retrospective observational study. SETTING: Five hospitals located in Wisconsin, Florida, Maryland, Michigan, and Alabama. PARTICIPANTS: We evaluated 19,236 births that occurred between April 1, 2011, and July 25, 2013. METHODS: Data were collected from electronic medical records and used to evaluate the risk of shoulder dystocia. Data were analyzed using a generalized linear mixed model, which controlled for clustering due to site. RESULTS: When insulin was prescribed, gestational diabetes was associated with an increased risk of shoulder dystocia (odds ratio = 2.10, 95% confidence interval [1.01, 4.37]); however, no similar association was found with regard to gestational diabetes treated with glycemic agents or through diet. Use of epidural anesthesia was associated with an increased risk for shoulder dystocia (odds ratio = 3.47, 95% confidence interval [2.72, 4.42]). Being Black or Hispanic, being covered by Medicaid or having no insurance, infant gestational age of 41 weeks or greater, and chronic diabetes were other significant risk factors. CONCLUSION: With the changing characteristics of pregnant women, labor and birth clinicians care for more pregnant women who have an increased risk for shoulder dystocia. Our findings may help prospectively identify women with the greatest risk.

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Shoulder dystocia is a rare but severe birth trauma where the neonate's shoulders fail to deliver after delivery of the head. Failure to deliver the shoulders quickly can lead to severe, long-term injury to the infant, including nerve injury, skeletal fractures, and potentially death. This observational study examined shoulder dystocia risk factors by race and ethnicity using a sample of 19,236 pregnant women who presented for labor and delivery from July 1, 2010 until June 30, 2013 at five locations. Multivariate analyses were used to identify risk factors associated with shoulder dystocia occurrence in racial/ethnic groups with high incidence rates. For White non-Hispanic mothers, the strongest risk factors were delivering past 40 weeks' gestation (odds ratio [OR] = 2.4; 95% confidence interval [CI] = 1.5, 3.9; p < .01) and use of epidural anesthesia during delivery (OR = 4.4; 95% CI = 3.0, 6.4; p < .01). Among Black non-Hispanic mothers, the risk factors with the greatest impact were use of epidural (OR = 5.3; 95% CI = 3.2, 8.7; p < .01) and having gestational diabetes and controlling the condition with insulin (OR = 4.6; 95% CI = 1.5, 13.8; p < .01). Additionally, among Hispanic mothers, having Spanish as primary language increased shoulder dystocia likelihood compared to those who did not cite it as their primary language (OR = 2.3; 95% CI = 1.1, 4.6; p < .05). This study provides evidence that risk factors for a labor and delivery condition can vary significantly across racial and ethnic subgroups. These differences emphasize the importance of evaluating risk by population subgroups and might provide a basis for labor and delivery clinicians to enhance personalized medicine to reduce adverse events.

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BACKGROUND: Identifying racial/ethnic differences in quality is central to identifying, monitoring, and reducing disparities. Although disparities across all individual nursing home residents and disparities associated with between-nursing home differences have been established, little is known about the degree to which quality of care varies by race//ethnicity within nursing homes. A study was conducted to measure within-facility differences for a range of publicly reported nursing home quality measures. METHODS: Resident assessment data on approximately 15,000 nursing homes and approximately 3 million residents (2009) were used to assess eight commonly used and publicly reported long-stay quality measures: the proportion of residents with weight loss, with high-risk and low-risk pressure ulcers, with incontinence, with depressive symptoms, in restraints daily, and who experienced a urinary tract infection or functional decline. Each measure was stratified by resident race/ethnicity (non-Hispanic white, non-Hispanic black, and Hispanic), and within-facility differences were examined. RESULTS: Small but significant differences in care on average were found, often in an unexpected direction; in many cases, white residents were experiencing poorer outcomes than black and Hispanic residents in the same facility. However, a broad range of differences in care by race/ethnicity within nursing homes was also found. CONCLUSION: The results suggest that care is delivered equally across all racial/ethnic groups in the same nursing home, on average. The results support the call for publicly reporting stratified nursing home quality measures and suggest that nursing home providers should attempt to identify racial/ethnic within-facility differences in care.

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OBJECTIVE: To identify what consumers want to know about nursing homes (NHs) before choosing one and to determine whether information preferences vary across race/ethnicity. DATA SOURCES/STUDY SETTING: Primary data were collected in Greater Boston (January 2013-February 2014) from community-dwelling, white, black, and Latino adults aged 65+ and 40-64 years, who had personal/familial experience with a NH admission or concerns about one. STUDY DESIGN: Eleven focus groups and 30 interviews were conducted separately by race/ethnicity and age group. PRINCIPAL FINDINGS: Participants wanted detailed information on the facility, policies, staff, and residents, such as location, staff treatment of residents, and resident conditions. They wanted a sense of the NH gestalt and were interested in feedback/reviews from residents/families. Black and Latino participants were especially interested in resident and staff racial/ethnic concordance and facility cultural sensitivity. Latino participants wanted information on staff and resident language concordance. CONCLUSIONS: Consumers want more information about NHs than what is currently available from resources like Nursing Home Compare. Report card makers can use these results to enhance their websites, and they should consider the distinct needs of different racial/ethnic groups. Future research should test methods for collecting and reporting resident and family feedback/reviews.

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